15% 30% $7,350 Individual Unlimited Individual (per calendar year) Out-Of-Pocket Maximum

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1 PLAN FEATURES Deductible (per calendar year) $1,750 Individual $20,000 Individual $3,500 Family $40,000 Family All covered expenses accumulate toward both the preferred and non-preferred Deductible. Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the calendar year. There is no Individual Deductible to satisfy within the Family Deductible. Member Coinsurance Applies to all expenses unless otherwise stated. 15% 30% Out-Of-Pocket Maximum $7,350 Individual Unlimited Individual (per calendar year) $14,700 Family Unlimited Family All covered expenses including Deductible accumulate toward both the preferred and non-preferred Payment Limit. Only those out-of-pocket expenses resulting from the application of coinsurance percentage, deductibles (except any penalty amounts) may be used to satisfy the Payment Limit. The family out-of-pocket limit can be met by a combination of family members; however no single individual within the family will be subject to more than the individual out-of-pocket amount. Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Lifetime Maximum Unlimited except where otherwise Unlimited except where otherwise Primary Care Physician Selection Optional Not applicable Certification Requirements - Certification for certain types of Non-Preferred care must be obtained to avoid a reduction in benefits paid for that care. Certification for Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home Health Care, Hospice Care and Private Duty Nursing is required - excluded amount applied separately to each type of expense is $400 per occurrence. Referral Requirement None None PREVENTIVE CARE Routine Adult Physical Exams/ Immunizations Covered 100%; deductible waived 1 exam per 12 months for members age 22 and older. Routine Well Child Exams/Immunizations Covered 100%; deductible waived 7 exams in the first 12 months of life: 3 exams in the 2nd 12 months life; 3 exams in the 3rd 12 months of life; 1 exam per 12 months thereafter to age 22. Routine Gynecological Care Exams Covered 100%; deductible waived Includes routine tests and related lab fees Routine Mammograms Covered 100%; deductible waived For covered females age 40 and over. Women's Health Covered 100%; deductible waived Includes: Screening for gestational diabetes, HPV (Human Papillomavirus) DNA testing, counseling for sexually transmitted infections, counseling and screening for Human Immunodeficiency Virus, screening and counseling for interpersonal and domestic violence, breastfeeding support, supplies, and counseling. Contraceptive methods, sterilization procedures, patient education and counseling. Limitations may apply. Routine Digital Rectal Exam / Prostatespecific Covered 100%; deductible waived Antigen Test For covered males age 40 and over. Colorectal Cancer Screening Covered 100%; deductible waived For all members age 50 and over. Routine Eye Exams Covered 100%; deductible waived 1 routine exam per 24 months PHYSICIAN SERVICES Page 1

2 Office Visits to PCP Includes services of an internist, general physician, family practitioner or pediatrician. Specialist Office Visits 15% coinsurance after deductible Pre-Natal Maternity Allergy Testing Allergy Injections DIAGNOSTIC PROCEDURES Diagnostic Laboratory and X-ray physician's office visit member cost sharing Diagnostic X-ray for Complex Imaging Services EMERGENCY MEDICAL CARE Urgent Care Provider (benefit availability may vary by location) Non-Urgent Use of Urgent Care Provider Emergency Room Covered 100%; deductible waived Covered as either PCP or specialist office visit after deductible Covered as either PCP or specialist office visit after deductible Preventative Lab and X-Ray covered in full. Diagnostic Lab and X-Ray 15% coinsurance after deductible- Free Standing Facility 25% coinsurance after deductible- Hospital Based If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable 15% after deductible- Free Standing Facility 25% after deductible- Hospital Based 15% after deductible Same as preferred care; after deductible Non-Emergency care in an Emergency Room Ambulance 15% after deductible 15% after deductible HOSPITAL CARE Inpatient Coverage Inpatient Maternity Coverage (includes delivery and postpartum care) Outpatient Surgery Outpatient Surgery (Freestanding Facility) Outpatient Hospital Expenses (excluding surgery) The member cost sharing applies to all Covered Benefits incurred during a member's outpatient visit MENTAL HEALTH SERVICES Inpatient Outpatient 15%; after deductible The member cost sharing applies to all covered benefits incurred during a member's outpatient visit ALCOHOL/DRUG ABUSE SERVICES Inpatient Outpatient 15%; after deductible Page 2

3 The member cost sharing applies to all Covered Benefits incurred during a member's outpatient visit Page 3

4 OTHER SERVICES Convalescent Facility Limited to 60 days per calendar year. 15% after deductible The member cost sharing applies to all covered benefits incurring during a member's inpatient stay Home Health Care Limited to 80 visits per calendar year. Includes Private Duty Nursing limited to 70 eight hour shifts per calendar year. Each visit by a nurse or therapist is one visit. Each visit up to 4 hours by a home health care aide is one visit. Hospice Care - Inpatient Hospice Care - Outpatient The member cost sharing applies to all covered benefits incurred during a member's outpatient visit Outpatient Short-Term Rehabilitation Limited to 30 Speech Therapy, 30 Physical Therapy and 30 Occupational Therapy visits per calendar year. Spinal Manipulation Therapy Limited to 20 visits per calendar year Autism Behavioral Therapy Covered same as any other Outpatient Mental Health benefit. Autism Applied Behavior Analysis Covered same as any other Outpatient Mental Health benefit with no age or visit limitations. Autism Physical, Occupational and Speech Therapy Covered same as any other Short Term Rehabilitation expense. No age or visit limit restrictions. Routine Hearing Exams 1 routine exam per 24 months Hearing Aids 15% after deductible Covered for children twelve years of age or younger. Nutritional Counseling Limited to 3 visits per calendar year. Durable Medical Equipment Teladoc 15% after deductible $40 per consultation Teladoc is available for minor acute, episodic illnesses or when your primary care physician is not available. Teladoc s U.S. board-certified doctors can resolve many of your medical issues, 24/7/365, via phone Teladoc ( ); or online video consults from wherever you happen to be. Teladoc may not be available in certain states and service limitations may apply (e.g., limited telephonic services for pharmacy in California). Transplants Mouth, Jaws and Teeth (oral surgery procedures, whether medical or dental in nature) Out of Area Dependents FAMILY PLANNING Infertility Treatment Diagnosis and treatment of the underlying medical condition. Vasectomy Tubal Ligation 15% Preferred coverage is provided at an IOE contracted facility only; after deductible Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible Coverage provided at the preferred and non-preferred benefit level of the plan; after deductible Covered 100%; after deductible 30% Non-Preferred coverage is provided at a Non-IOE facility; after deductible Page 4

5 PHARMACY Pharmacy Plan Type GENERAL PROVISIONS Dependents Eligibility Pre-existing Conditions Exclusion National Health Care, Inc. N/A N/A Spouse, children from birth to age 26, regardless of student status. On effective date: Waived After effective date: Waived This plan does not cover all health care expenses and includes exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased by your employer. All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents; Charges related to any eye surgery mainly to correct refractive errors; Cosmetic surgery, including breast reduction; Custodial care; Dental care and X-rays; Donor egg retrieval; Experimental and investigational procedures; Hearing aids; Immunizations for travel or work; Infertility services, including, but not limited to, artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in your plan documents; Nonmedically necessary services or supplies; Orthotics; Over-the-counter medications and supplies; Reversal of sterilization; Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies, or counseling; and special duty nursing. Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions. Page 5

6 This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee results or outcomes. Consult the plan documents (i.e. Group Insurance Certificate and/or Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitations relating to the plan. With the exception of Aetna Rx Home Delivery, all preferred providers and vendors are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change without notice. Some benefits are subject to limitations or visit maximums. Certain services require precertification, or prior approval of coverage. Failure to precertify for these services may lead to substantially reduced benefits or denial of coverage. Some of the benefits requiring precertification may include, but are not limited to, inpatient hospital, inpatient mental health, inpatient skilled nursing, outpatient surgery, substance abuse (detoxification, inpatient and outpatient rehabilitation). When the Member s preferred provider is coordinating care, the preferred provider will obtain the precertification. When the member utilizes a non-preferred provider, Member must obtain the precertification. Precertification requirements may vary. Depending on the plan selected, new prescription drugs not yet reviewed by our medication review committee are either available under plans with an open formulary or excluded from coverage unless a medical exception is obtained under plans that use a closed formulary. They may also be subject to precertification or step-therapy. Non-prescription drugs and drugs in the Limitations and Exclusions section of the plan documents (received after open enrollment) are not covered, and medical exceptions are not available for them. While this information is believed to be accurate as of the print date, it is subject to change. Plans are administered by Aetna Life Insurance Company. Page 6